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Time to Revisit Medical Education ... and Not Just for Physicians

— Do docs spend too much time in school, or do NPs and PAs not spend enough?

MedpageToday
A group of medical school students in an anatomy class

Medical schools make physicians. This has been the case for quite a long time. The modern medical school has existed, in something like its current form, since medical schools were reformed in the wake of the . That report, commissioned by the Carnegie Foundation, recommended standardized premedical and medical education and really created the modern medical college.

Fortunately for untold patients, the report also resulted in closure of many suboptimal medical schools, saving patients from many poorly trained "physicians." (Some of those students had no clinical training and attended lectures only, and did so part-time.)

The resulting system, which we have now, requires 4 years of undergraduate education with certain science prerequisites and then requires 4 years of medical school, the first two devoted to basic sciences like anatomy and physiology, pharmacology and pathology; the second two years a hands-on, bedside education in patient care.

Medical schools select excellent students who have high GPAs and good scores on the Medical College Admissions Test, or MCAT. Admissions committees are looking for students who have demonstrated a capacity to take difficult classes involving many semester hours of classwork. But it is important that they also have appropriate personalities and understand how to relate to others even as they excel academically. These students volunteer, work in allied health fields, work as "scribes" (charting for physicians), shadow professionals, engage in research, and belong to various organizations that they often lead.

This process is more than virtue signaling. The premedical education is designed to create students capable of retaining a large amount of information, applying it, and engaging in multiple activities, as well as interacting well with others. This is how medicine often feels. Like an exercise in endless multitasking and test-taking, as each day requires medical doctors to access complex information filed in their memories and apply it to complex situations in real-life humans who are suffering, hurting, tired, frightened, and sometimes difficult.

After undergraduate education, medical school is more of the same, except that the volume of information is greater. While a busy undergraduate semester might involve 18 credit hours of classwork, an average medical school semester is about 20-25 credit hours. And this for four semesters in a row. But again, this is a way of "learning to learn."

When the students then enter their second 2 years of medical school, it is to spend time with the various physician specialties and in many settings. Students spend months with family physicians in offices or clinics, with pediatricians admitting children, with internists in the intensive care unit, with cardiologists in the cardiac cath lab, with surgeons in the operating room, with obstetricians in labor and delivery. The list goes on and on. In fact, it goes on to the tune of about 4,000-6,000 clinical hours spent during the second half of medical school. All the while, their previously developed capacity to assimilate large quantities of information continues to grow.

While traversing those thousands of clinical hours the students learn to apply all of their academic information to the very real human beings who will populate their future offices, EDs, surgery suites, and clinics. They learn to perform procedures, talk to the suffering, write prescriptions, dose medications in the hospital, give bad news, and interact with other physicians.

They learn the "terror of error" that comes with the profession. Mistakes in medical school are formative because generally, the student is not primarily responsible for a patient. But they cause embarrassment and sometimes result in the student being called out publicly before other students and residents.

"Mistakes are dangerous" is a mindset useful in a person who will be responsible for the lives of others. In the end, however, the goal is to create diligence and accountability in the care of human beings, for whom the errors of physicians can be life-altering or life-ending.

Subsequent to medical school, students enter into residency programs that last anywhere from 3 to 7 years. Based on the specialty the resident is pursuing, their training may be followed by fellowship programs in subspecialties. While medical school lays the foundation of the practice of medicine, residency and fellowship hone that training so that afterward, the graduate knows how to diagnose and treat within his or her area of expertise. Residency is where the student really learns to become a physician. Depending on the specialty, residency and fellowship together can account for 10,000 to 20,000 or more clinical hours before completion. These involve hours spent talking to, examining, and treating patients, as well as performing charting and educational activities.

There is significant nationwide regulatory oversight for medical schools, residencies, and fellowships. Standardized testing in medical school and after helps ensure appropriate educational standards. Such testing then goes on in the form of specialty board examinations after residency or fellowship training. Furthermore, medical boards now require ongoing, yearly education as part of what is known as "maintenance of certification."

It's a long process that is intellectually, morally, and financially rewarding. But it is costly in terms of educational debt, income deferred, and years offered on the altar of learning and professionalism. It takes a toll on the personal life and emotions of those committed to the path. However, physicians educated in this manner are well-prepared to care for the sick and injured, often tempered with a deep sense that despite their learning, there is always more to know.

These days, however, we are entering into new territory in medical education, as advanced practice providers (APPs) are steadily providing ever more care, in ever more diverse settings in medicine.

APPs are healthcare professionals who are not physicians, having been educated in alternate pathways. They include physician assistants, anesthesia assistants, nurse practitioners, doctors of nursing practice, nurse anesthetists, and nurse-midwives.

APPs may have master's or doctoral degrees, and indeed some have much more clinical exposure than others in training. However, in the case of nurse practitioners and doctors of nursing practice, many programs are predominantly online. In fact, there are a number of online programs that allow an associate's degree registered nurse to obtain a master's degree as a nurse practitioner.

The amount of clinical contact required in online NP programs is an average of 500 hours. In years past, students in those programs had often practiced nursing at the bedside for many years and it was believed that such exposure made up for the shortened path to clinical practice since they had already seen, and done, so much. However, all too many programs now allow minimal experience before moving on into those courses of study, and subsequently, practice.

Physician assistants, who spend just over 2 years in training, sometimes have previous experience as nurses, EMTs, paramedics, or military medics. In their programs they have a highly compressed first year of didactics, followed by an average 2,000 hours of clinical education before they graduate with their master's degree. Although their didactics are more intense than that of online nurse practitioner programs, even their clinical hours fall far short of those involved in the education of a medical student and then resident or fellow.

Despite these differences, APPs are being used in many specialties, including surgical/procedural fields, right out of training. They are taking calls for physicians, rounding on patients, and performing procedures in surgery suites or intensive care units. (Leading some physicians to question the value of their own hard-earned specialty board certifications.)

In fact, APPs are often side-by-side with medical students and residents in training and competing with them for experience with procedures. Medical students increasingly report being trained by nurse practitioners while on rotations, even in academic centers.

Given that many patients struggle to find physicians, the rise of the APP makes sense. Especially since physicians frequently have long waiting lists for new patients, and are often overwhelmed in their practices with paperwork, electronic medical records, billing requirements, meetings, and the actual patient care which is supposed to be their "raison d'être."

While there is no question that many APPs provide excellent care within well-defined parameters, it is also the case that they are trying, and succeeding, to reach beyond those limitations and in many cases successfully lobbying states for full practice authority without any oversight from physicians. Physician oversight was typically required, and desired, in the earlier days of those professions. Now, the national organizations for APPs often argue that physician oversight is unnecessary.

Many physicians now have questions about this paradigm. Although those who object are often charged with bullying or financial protectionism (and indeed, no physician wants to be replaced), it is even more the case that physicians have another concern. And that is the legitimate fear that persons are being allowed to act as physicians with only a fraction of the training of physicians; and that this is an unsafe trend.

Advocates for APPs suggest that these programs are essentially a more expeditious way to learn to do the same work as physicians, particularly in primary care. Admittedly, maybe this is an idea whose time has come. Perhaps we will learn, in time, that outcomes are the same with this new educational system.

It would be ludicrous to believe that medical education will never change. Certainly, the way we make physicians today is both arduous and expensive, and in fact, the cost of that education is borne by both taxpayers who fund medical schools and patients who pay medical bills. Debt and fatigue, along with burnout, lead to depression and sometimes suicide among medical students and resident physicians in training. Surely some change is in order; and some changes have happened in terms of work-hour limitations.

It's likely that we can improve the system of medical education. The problem is that we don't have enough data on outcomes to simply state that an APP is the same as a physician. For all that states expand their practice, and more and more APPs are graduating and caring for patients, the numbers just aren't there to demonstrate that it's time to dramatically overhaul the system.

Tragically, physicians in both training and practice are finding themselves reprimanded, or dismissed, for even suggesting that somehow their education, their knowledge, and skills, are superior to those of APPs. In a kind of "medical Marxism," everyone has to be equal. But that's poor science and has a chilling effect on attempts to investigate the APP model.

Other physicians have found themselves facing a different problem, but one equally worrisome. They have found themselves involved in malpractice litigation because they were mandated to act as supervising physicians for APPs but were not involved in their hiring and did not have the time to see every patient or review every chart, cared for by an APP and ensure that standards of care were met. This is especially troubling since many physicians have found themselves working with new APP graduates who were caring for very complicated patients that even physicians would find difficult.

Maybe medical school should be shorter and cheaper. But given that many APP programs are co-located with medical schools and residencies, then the administrators of those programs need to be honest and do the research. And then offer to reduce the cost to medical students if their APP colleagues will be doing their jobs, but for a fraction of the time and cost and for salaries steadily approaching those of some physicians. In fact, maybe some loan debt reduction would be in order if that is the case!

It is doubtful that any dean is interested in that possibility. Therefore, honest research is in order. Perhaps it's time for a nationwide revisitation of the Flexner Report. Perhaps we need an evaluation, by a neutral organization, with an eye not only to DO and MD programs, but to APP programs across the land.

While we're at it we can evaluate chiropractic programs, naturopathic programs, and any other program that offers a pathway to practice medicine.

If it's time to shorten medical school, then so be it. However, truncating it may not be the right answer. For all of the difficulties of the medical education process in the United States, it continues to produce outstanding physicians. And part of the reason it does has to do with the things that make it so difficult.

Ultimately, medical school works, and medical school matters. And before we jettison the idea, or undercut its value, we should take a long hard look at the care being provided outside of the physician model.

Who knows? Maybe we'll all be surprised. But if nothing else, we'll be wiser and safer for stepping outside politics, economics, and tradition and taking a hard look.

I think Abraham Flexner would approve.

is an emergency physician who blogs at and is the author of and .